70 years on: what is the path ahead? - Professor Terry Young BSc PhD FBCS

The National Health Service was founded six years before the first kidney transplant [1], when X-rays were still captured on film, and moving images and contrast media were still radiological novelties [2]. Meanwhile, a nascent pharmaceutical sector was learning to produce penicillin in quantity while seeking to plan drug discovery rather than waiting for happy accidents. However, the seminal event of the 1940s was the birth of the NHS with the idea, not of heroic medicine performing miracles for the lucky few, but of mundane medicine that worked for millions. Indeed, the heroic and mundane characterised the next 70 years in a struggle to manage the migration of the heroically expensive to the affordably mundane in delivering mass-medicine.

This quest is a very British story about evidence, social conscience, policy and funding. The British Doctors Study ran for half a century from 1951 but within 4 years had demonstrated the link between smoking and cancer[3]. It confounded popular belief – that smoking was good for you – and established clinical investigation as the way to make medical choices, following Hill’s breakthrough randomised controlled trial (RCT) of streptomycin in 1948 [4]. Clinical trials typically divide a group of people (e.g. with pulmonary TB) into two groups at random (so that they are as similar as possible). One is given the intervention under test (administrating streptomycin) while the other is not, and the outcomes (recovery from TB) are counted. For those interested in the history of trials, the James Lind Library has more information[5]: it is named after the eighteenth century Scottish physician who conducted an early trial to show how citrus fruit could end scurvy.

In 1972, another Scottish doctor, Cochrane, advocated widespread use of RCTs and that all specialties periodically summarised those RCTs in a systematic way that would inform practice. The global Cochrane Collaboration and it systematic reviews of healthcare interventions [6] remains to this day and his book [7] is still in print. With the establishment of NICE (now the National Institute for Health and Care Excellence) in 1999 [8], the struggle between the heroic and the mundane took a new turn as the NHS set the production of guidance upon a combination of trials results and economic principles to assess when society (through the NHS) should pay for a treatment. The open appeal to affordability – alongside safety, efficacy or performance – was initially radical, and the role of NICE is now embedded in law through the Health and Social Care Act (2012).

So what lies ahead in the battle between the heroic and the mundane? So far, against a backdrop of incredible advances in what can be imaged, diagnosed, and treated, the NHS has applied a combination of clinical evidence and economics to interpret its original mandate in the rough and tumble of care for everyone, free at the point of delivery. With cost and capacity pressures likely to intensify under the heightened expectations of a population that lives longer and with longer periods of illness, we must ask how the NHS can address quality and affordability in new ways.

An obvious challenge lies in converting the best evidence to best practice, itself a twofold problem. First, doctors do not always implement what is known to be best, especially if doing so presents practical problems. Thus, prescribing practice tends to comply better with NICE guidelines than surgical procedures or the use of medical devices[9]. Moreover, the guidance must convince the doctor[10]: implementation of evidence rarely follows a linear approach and doctors typically apply heuristics and “mindlines” [11]. So, turning what we know into what we do is a major challenge.

Second, we must look beyond individual clinical decisions, since, even if technology and drugs were free, healthcare costs would still spiral because salaries are the main budget item. The efficiency and effectiveness with which the NHS uses the time of its staff is probably the biggest challenge facing it in the 21st Century. We do not know how much NHS staff time is lost because we do not measure service failure. The next patient may appear because something has gone wrong or simply through the illness: most of the time it is hard to know. In spite of waves of initiatives to improve the way that care is delivered, blockages and overflows persist, resisting attempts to restructure the workforce[12] or change hospital flows and emergency provision[13]. The second big quest, is for better design of infrastructure and operational processes, systematically implemented. These challenges throw a fresh light on evidence, since our data-rich world – social media, clinical records, pharmacy transactions, transport links, and even the weather – yields information to be mined and used to design better patient experiences and outcomes. Healthcare services themselves generate data that can be harvested with smart sensors – smartphones, even – and analysed by information systems to boost performance and efficiency of the system and the experience of patients. A fresh look at the information and data sources available is therefore needed – especially in view of the upcoming revolution in artificial intelligence – along with research to forge it into consistent forms of evidence that can guide service delivery as well as clinical decisions. It is hard to overestimate the value of the information to which we can gain access, once we can mine it and turn it into knowledge that will drive better decisions for everyone. This is a third big challenge.

The final piece of the puzzle is business models that reward outcomes and better experiences. Through the Quality and Outcomes Framework[14] and Payment by Results[15], the NHS has experimented with getting value for money. So far, the experience has been mixed and often incentives simply drive more activity. Our fourth quest, then is for a consistent way to go about the business of provision.

In setting up the NHS, the UK government committed to do something dramatic and to attend to the practicalities afterwards. Seventy years down the line, we are still in awe of this resolve and must not underestimate the many, often hidden, problems that the NHS has solved with innovation and panache. Its back-to-front approach of starting with the dream and then working out how to keep it alive has proved remarkably robust.

The final question is whether the NHS should continue to retro-engineer fixes or whether it needs something more fundamental. The dream is viable, but there is a strong case to recast it in formal design. We now know enough about quality, evidence and funding models to specify what we really want, and during the same 70 years, industry has taken service design into unimagined realms of performance and efficiency. In doing so it has cracked many of the logistics, information management, and process control problems that beset the NHS. We can have a very different NHS.

So, after 70 years, the NHS question is still about resolve rather than viability: do we really want it?